Last week, 217 Republican members of the House of Representatives passed a bill that, if it becomes law, will leave millions of people without health insurance. We don’t have a good grasp of how many millions will be harmed, because they were in too much of a hurry to wait for an estimate from the nonpartisan Congressional Budget Office — or, in some cases, to read the bill they were voting on. My guess is that most of those members know it’s a terrible bill that will harm many of their constituents, and they’re hoping the Senate will fix the mess they’ve made.
Like the original American Health Care Act, this one will leave states with an estimated $880 billion less in Medicaid funding over the next decade; deny Medicaid reimbursements to Planned Parenthood, which provides reproductive healthcare to more than two million people, many of whom are low-income and have few other sources of such care; allow insurers to charge their oldest clients five times as much as their youngest clients (instead of the ACA’s 3:1 ratio); and redistribute subsidies for those who buy individual plans on health insurance exchanges so that those who are older or have lower incomes will be far less likely to be able to afford the premiums. CBO did score this proposal, and calculated that it would result in 24 million people losing health insurance coverage by 2026.
In addition, the amended AHCA gives states the option to make individual marketplace plans less valuable and farther out of financial reach for those who’ve experienced hardships. If this horrible bill becomes law, insurers in the states that accept this waiver option can raise premiums on those with pre-existing conditions if they experience gaps in coverage. Those who are able to get insurance could see its value drop in states that redefine essential health benefits to exclude things like maternity care and prescription drug coverage. Representative Tom MacArthur (R-New Jersey) is responsible for this amendment, and I hope his constituents are taking note.
In short, people will lose insurance coverage, and many of those who retain it will find it covers less than it used to. Planned Parenthood will probably have to reduce the services it provides or the number of clients it serves with contraception, STI testing, and breast cancer screenings. Community health centers and hospitals with emergency rooms will find themselves in more precarious financial positions, because they’ll still be providing care to all who need it but fewer of those patients will have insurance. Insurers who offer marketplace plans will probably suffer, too, because potential customers with incomes under 400% of the federal poverty level will no longer receive subsidies designed to put insurance in financial reach — i.e., fewer people will be able to afford the product they’re selling.
There are two primary reasons I can think of why 217 House Republicans voted for a bill that would do so much damage. One is that they care more about tax cuts than about millions of people losing health insurance: The original AHCA’s estimated $880 billion in Medicaid cuts came alongside tax cuts worth about $883 billion, the vast majority of which would benefit households with annual incomes above $200,000. Maybe some Representatives even convinced themselves that this massive shift of resources from the poor to the rich is good for the country as a whole; if so, their values obviously differ substantially from mine.
Another possible reason to vote for this bill is caring more about one’s political future than about the health and wellbeing of one’s constituents. Vox’s Ezra Klein described the scenario in the 5/3 episode of The Weeds podcast as passing the hot potato: The House Freedom Caucus didn’t want to be blamed for killing the long-promised Obamacare “replacement,” so they worked out a way to modify the bill to include even fewer consumer protections. That put the hot potato in the hands of those who might object to the degradation of insurance coverage and quality. Representative Fred Upton (R-Michigan) expressed concern about how people with pre-existing conditions would fare, but then claimed those concerns were assuaged with the creation of an $8 billion fund that states accepting the MacArthur waiver option could use to assist those who see their premiums jump. This Upton amendment is both nonsensical policy and a far smaller amount than would likely be needed to truly offset the damage, but it allowed Upton to vote for the bill. Now the hot potato is in the Senate’s hands.
In the Senate, 13 white men constitute the working group developing that chamber’s bill — even though the AHCA would have a disproportionately negative impact on women, and even though there are five Republican Senators who are women.
As the Senate considers healthcare legislation, I hope they’ll prioritize public health over politics. Risking burning one’s hands on a metaphorical hot potato seems like the kind of sacrifice one should be willing to make so millions of people can continue getting healthcare.